Lacrimal Sac Research Articles

Dermoid cyst simulating mucocele of lacrimal sac: A case report

A dermoid cyst in the orbit is a choristoma (clump of normal tissue in an atypical location). It results from the migration of ectoderm to a hypodermic location along embryonic lines of closure. Orbital dermoid cysts are usually located superiorly, either temporal or nasal. A dermoid cyst situated close to the lacrimal sac area is extremely rare (Only six published cases to the best of our knowledge). Here, we report a case of a dermoid cyst presenting with swelling over the lacrimal sac area simulating mucocele. The mass was excised by an external dacryocystorhinostomy (DCR) incision approach and the histopathological examination revealed a dermoid cyst. Although rare, the dermoid cyst should also be considered as one of the differential diagnosis in case of swelling in the lacrimal sac area.

Dacryoscintigraphy as a guide for surgery in patients with functional epiphora

ObjectifDéterminer les éventuels bienfaits de la dacryoscintigraphie (DSG) dans la planification du traitement chirurgical de l’épiphora fonctionnel. MéthodesIl s'agit d'une étude multicentrique rétrospective portant sur une série de patients qui présentaient un larmoiement symptomatique en l'absence de cause externe nette et chez lesquels l'irrigation lacrymale et le sondage du canal lacrymal étaient normaux (en d'autres termes, un épiphora fonctionnel). Tous les patients ont subi une DSG avant l'intervention. Les patients ont été exclus si la DSG n’était pas en mesure de mettre au jour une obstruction de l’écoulement lacrymal. Les patients qui présentaient un retard de l’écoulement lacrymal avant son entrée dans le sac lacrymal (« pré-sac ») pendant la DSG ont subi une chirurgie visant à améliorer l’écoulement dans le sac lacrymal. Les patients qui présentaient un retard de l’écoulement lacrymal après le sac lacrymal (« post-sac ») pendant la DSG ont subi une dacryocystorhinostomie. La réussite chirurgicale reposait sur l'un des 3 critères suivants : disparition complète, amélioration significative ou amélioration partielle de l’épiphora. L'absence de modification ou l'aggravation de l’épiphora comparativement à la période préopératoire étaient considérées comme un échec de la chirurgie. RésultatsUn total de 77 chirurgies (53 patients) réalisées sous DSG ont été incluses. On a noté 14 cas (18,2 %) de retard de l’écoulement de type « pré-sac » et 63 cas (81,8 %) de retard de type « post-sac ». Le taux de réussite chirurgicale dans l'ensemble de la cohorte a été de 83,1 %. Le taux de réussite a atteint 100 % dans le groupe « pré-sac » et 79,4 % dans le groupe « post-sac » (p = 0,06). Le suivi moyen a été de 22 mois (é.-t. : 21 mois). ConclusionNous avons été en mesure d’établir l'utilité de la DSG dans la planification du traitement chirurgical de l’épiphora fonctionnel. Comparativement à l'intubation lacrymale empirique ou à la dacryocystorhinostomie, la démarche reposant sur la DSG peut être particulièrement utile dans l’épiphora fonctionnel de type « pré-sac ».

A Comparative Study Between Anterior-Posterior and Superior-Inferior Flap Suturing Technique in Endoscopic Dacryocystorhinostomy at our Tertiary Institution.

The Nasolacrimal sac inflammation, also known as dacryocystitis, is frequently accompanied by nasolacrimal duct blockage at the confluence of lacrimal sac and duct. Treatment of choice for dacryocystitis is dacryocystorhinostomy (DCR), which can be done through external approach and endoscopic approach. The endoscopic DCR has distinct advantage over the external DCR as there is no facial scar& also it maintains the pump action. We have used flap suturing technique of endoscopic DCR in our study where in lacrimal sac medial flap is sutured to nasal mucosal lateral flap wherein patients were selected into either of the two groups such as Anterior-Posterior type (group A) and Superior-Inferior type (group B) of Flap suturing technique. Aim and objectives of the study were to compare the subjective and objective success rate between group A & B of flap suturing used in endoscopic DCR & to compare the success rate of our techniques with other techniques in literature. Our study was Duration based prospective observational study with a Duration of one year from June 2021 till June 2022 with study population comprised of patients in age group of 20 to 70years, with complaints of watering of eye (epiphora) attended ENT Department of our institute during this one year. Study population comprised of Total of 86 patients (100 eyes) of which 45 patients (51 EYES) underwent anterior- posterior flap suturing (Group A) and 41 patients (49 eyes) underwent superior- inferior flap suturing (Group B) technique of endoscopic DCR The mean age ± standard error of mean was 45.1765 ± 1.5 and 49.0816 ± 1.9 in group A & B respectively,which was not statistically significant (p value = 0.994). The male and female patients in group A & B was 27.45%,72.54% and 34.69%,65.30% respectively which was not statistically significant (p value = 0.434). At each follow‑up, subjective success rate was more in group A that indicated a better trend of success for that group. However, the difference in the success rate was not statistically significant.The objective success rate between the two groups were more or less similar & was not statistically significant. The subjective success rate in both Anterior-Posterior type (group A)and Superior-Inferior type (group B) of Flap suturing techniques of endoscopic dacryocystorhinostomy were more or less similar with regards to absence of epiphora but objective success rate with regards to the patency, were almost similar with a shift of trend from Group A to group B at 6months follow up and we also found that complications in both the groups were very few, without statistically significant difference between them. In terms of success rate and complication,The endoscopic DCR with flap suturing technique found to be more or less similar with previous techniques of DCR described in the literature.

Topographic and anatomical features of the nasolacrimal duct obstruction due to radioiodine treatment.

To investigate the topographic and anatomical features of secondary acquired nasolacrimal duct obstruction (SALDO) due to radioiodine therapy. Dacryocystography-computed tomography (DCG-CT) scans of the nasolacrimal ducts in 64 cases with SALDO due to radioiodine therapy and in 69 cases with primary acquired nasolacrimal duct obstruction (PANDO) were studied. The anatomical site of obstruction was located, and morphometric characteristics of the nasolacrimal ducts were calculated: volume, length, and average sectional area. The statistical analysis was performed using the t-criterion, ROC analysis, and the odds ratio (OR). The mean nasolacrimal section area was 10.7 ± 0.8mm2 in patients with PANDO and 13.2 ± 0.9mm2 in patients with SALDO due to radioiodine therapy (p = 0.039); the AUC value in ROC analysis for this parameter was 0.607 (p = 0.037). The development of "proximal" obstruction including lacrimal canaliculi obstruction and obstruction at the site of the lacrimal sac was 4.076 times more likely (CI: 1.967-8.443) in patients with PANDO than in patients with SALDO due to radioactive iodine exposure. By comparing CT scans of the nasolacrimal ducts, we observed that in SALDO obstruction due to radioactive iodine therapy is predominantly "distal," while in PANDO it is more often "proximal." The development of obstruction within SALDO is followed by more pronounced suprastenotic ectasia.

Modified Horner-Duverney's muscle plication in the treatment of functional epiphora.

The orbicularis oculi muscle, especially its part (Horner-Duverney's muscle), which is surrounded by the pericanalicular and located deep in the lacrimal sac, is of primary importance in all stages of tear fluid flow. This study aimed to demonstrate that tightening the pretarsal-preseptal orbicularis oculi and Horner-Duverney muscles may improve the function of the lacrimal pump and may be a surgical alternative for treating functional epiphora. This was a prospective interventional case series of 28 patients with functional epiphora. During surgery, sutures were used to perform the intervention, and these were first passed through the upper and lower eyelid pretarsal-preseptal orbicular muscles, through the Horner-Duverney's muscle, and finally, through the dacriocystorhinostomy incision and tightened. Each patient completed the Lac-Q questionnaire and Munk scale prior to surgery, as well as six weeks and six months later. Before surgery, a fluorescein dye disappearance test was performed, which was repeated at follow-up appointments. Pre- and post-operative data were analyzed and compared at the most recent visit. Twenty-eight patients (10 males and 18 females) with a mean age of 59 ± 35 years were included in this study. The severity of epiphora and its tearing effect on daily life significantly improved following the operation. The fluorescein dye disappearance test result was significantly improved after 6 weeks of followup in %89.3 of eyes and at 6 months followup in 92.9% of eyes. The Lac-Q questionnaire's mean social impact scores improved significantly postoperatively, from 3.76 to 0.77 (p < 0.001). The changes in total scores (7.29 before surgery to 1.71 after 6 months) were statistically significant (p < 0.001). The Munk score success rate was 64.3% and 85.7%, respectively. No significant complications or adverse effects were observed. Our findings suggest that a beneficial and seemingly simple, safe, and easy procedure to reduce functional epiphora is to tighten the preseptal-pretarsal orbicularis and Horner-Duverney's muscles.

Диагностическая ценность трехмерной компьютерной реконструкции слезоотводящих путей и моделирования слезоотведения у пациентов с эпифорой

Perpose. To demonstrate diagnostic value of three-dimensional computional reconstruction of the lacrimal ducts and modeling of lacrimal drainage for patients with epiphora. Material and methods. The study involved 10 patients with epiphora, parameters of lacrimal sac and nasolacrimal canal were measured, a multislice computed tomography (MSCT), MSCT with contrast and three-dimensional modeling of the passage of tears and canaliculi tests were performed. Results. Patients with lacrimal sac dilation and a slight narrowing of the proximal part of the nasolacrimal canal have no changes according to CT with contrast, but have a retrograde flow from lacrimal sac, registered by means of three-dimensional computional reconstruction. Conclusion. Three-dimensional reconstruction of the lacrimal ducts and computer simulation of lacrimal passage is a useful tools for a negative canaliculi test in patients with epiphora and no changes according to contrast-enhanced CT. Keywords: epiphora, stenosis of lacrimal paths, multiplanar computer tomography with contrast, three-dimensional computional of lacrimal drainage

Dacryocystectomy: A fibrin glue-assisted subfascial excision.

This article describes a technique of dacryocystectomy involving dissection within the subfascial plane, in which the lacrimal sac fascia is preserved and the orbital fat remains undisturbed. The lacrimal sac cavity was directly injected with Tisseel fibrin glue mixed with trypan blue. This led to sac distension and facilitated its separation from surrounding periosteal and fascial attachments. Staining the lacrimal sac epithelium improved definition of the mucosal lining. Transverse sections of the lacrimal sac specimen were histologically analyzed, which confirmed that dissection was completed within a subfascial plane. The technique herein described facilitates en bloc excision of the lacrimal sac without breaching the fascial plane that separates the sac from orbital fat.

MICROBIOLOGICALAND CLINICAL SPECTRUM IN CHRONIC DACRYOCYSTITIS

Background: Dacryocystitis is the inammation of the lacrimal sac which is usually because of nasolacrimal duct obstruction. It is a major cause of ocular morbidity especially in females. Bacterial chronic dacryocystitis is more common than acute dacryocystitis. Objective: To isolate and identify various types of bacterial agents associated with Chronic Dacryocystitis and to assess the association between clinical presentations with chronic dacryocystitis. Methods: 60 patients diagnosed with chronic dacryocystitis were recruited for this study. Gram staining , culture and sensitivity of bacterial agents were done. Results: The disease had a prediction to the left side especially in females. Both gram positive and gram negative organisms are associated with chronic dacryocystitis with highest incidence of Staphylococcus aureus (26.7%) followed by Streptococcus pneumonia (6.7%) among the gram positive organisms while among the gram negative organisms, Pseudomonas aeruginosa (13.3%), Proteus mirabilis (1.7%) and Morganella mogenii (1.7%) were predominant. Most of the isolates of Staphylococcus aureus were sensitive to Gentamycin whereas Streptococcus pneumonia showed sensitivity to Tetracyclin, Levooxacin, Tigecycline and Chloremphenicol. Conclusion: Both gram positive and gram negative organisms are associated with chronic dacryocystitis. Knowledge of the bacteriology of dacryocystitis and the susceptibility of the bacteria towards antibiotics will both guide a clinician in the choice of the medication for the appropriate drug for treatment

The influence of microorganisms on early relapses after external dacryocystorhinostomy.

Understanding the influence of microorganisms in patients with acquired nasolacrimal duct obstruction (NLDO) and investigating their effect on recurrence after external dacryocystorhinostomy (DCR). This prospective study included 50 patients. Evaluations were made before, on the first postoperative day and monthly after DCR. Nasolacrimal silicon tubes (NST) were removed after three months. Before the DCR, swab samples were taken from both hands and lower conjunctival fornices and from the lacrimal sac during the first DCR and from the relapsed cases during the second DCR. Growth was observed in 90 (45%) cultures out of 200 and a total of 23 different strains were identified altogether. Staphylococcus aureus (40%) and Streptococcus pneumoniae (28%) were dominantly isolated which were all resistant to penicillin, tetracycline and erythromycin. Lacrimal syringing (LS) was successful in patients (100%) on the first postoperative day. After three months, before NST removal, purulent discharge from the punctum was observed in five patients, and blockage was detected by LS. S. pneumoniae was isolated from all five patients' obstructed side conjunctival cultures. Additionally, from their lacrimal sac, S. pneumoniae (4 patients), Capnocytophaga gingivalis, and Candida spp. (1 patient) strains were isolated. S pneumoniae was isolated in four out of five patients from the ipsilateral conjunctival and lacrimal sac cultures which obtained from the subsequent DCR. Our results showed that S. pneumoniae was an isolated and persistent strain in cases with early recurrence even after a successful DCR.

Primary lacrimal sac lymphoma: a case-based retrospective study in a Chinese population.

To determine the clinical characteristics, pathological types, tumor markers, treatments, and outcomes of Chinese patients with primary lacrimal sac lymphoma. This case-based retrospective study analyzed 15 Chinese patients with primary lacrimal sac lymphoma. The clinical data collected included gender, age at diagnosis, symptoms, imaging examination results, pathologic diagnosis, pathogen identification, tumor markers, treatments, follow-up, and prognosis. Descriptive statistics were used to characterize the patients. Progression-free survival (PFS) was defined as the time from surgery to the last follow-up, first record of tumor recurrence, or death. There were 7 males and 8 females with unilateral primary lacrimal sac lymphoma in the left eye (n=6) or right eye (n=9). The initial symptom in 13 patients was epiphora, and 2 patients had redness and swelling in the lacrimal sac area. All patients ultimately developed epiphora, and 12 had masses in the lacrimal sac area. Analysis of preoperative plasma tumor markers indicated 14 patients had elevated homocysteine, 9 had elevated β2-microglobulin, and 2 had elevated lactate dehydrogenase (LDH); 2 patients had elevations of all three markers, and 1 patient had no elevation of any marker. All patients underwent surgical resection and 12 patients received postoperative chemotherapy. The pathological types were DLBCL (n=8), MALT lymphoma (n=5), and NK/T-cell lymphoma, nasal type (n=2). The mean follow-up time was 25.8mo (range: 4-41) and 2 patients died. Seven patients who underwent mass excision combined with dacryocystorhinostomy (DCR) had no postoperative epiphora. Eight patients who only underwent mass excision had varying degrees of postoperative epiphora. Preoperative LDH elevation and NK/T-cell lymphoma, nasal type were associated with poor prognoses. Early diagnosis and treatment can lead to a good prognosis for most patients with primary lacrimal sac lymphoma. Mass resection combined with DCR can reduce the occurrence of post-surgical epiphora. The pathology type and tumor marker status are associated with prognosis.

ENDOSCOPIC DACRYOCYSTORHINOSTOMY WITH STENTING – OUR EXPERIENCE IN A TERTIARY CARE CENTER

Background: The dacryocystorhinostomy (DCR) is a surgery aiming in formation of fistula of the lacrimal sac into nasal cavity. It is the preferred method of therapy for nasolacrimal duct blockage distally. Ophthalmologists and ENT surgeons both perform it. The development of surgery that increases surgical effectiveness is silicone stenting. Materials And Method: Between 2013 and 2022, 50 patients underwent surgery in Department of ENT, Sapthagiri Institute of Medical Science and Research, Bangalore. To arrive at a clinical diagnosis, a complete physical examination and a thorough history were performed. Endoscopic Dacryocystorhinostomy with silicone stenting was performed as the primary form of treatment. In individuals with nasolacrimal duct blockage, endoscopic DCR with stenting is safer Conclusions: and more affordable than external DCR.

Giant lacrimal mucocele in an adult – A case report

Encysted lacrimal mucocele refers to diffuse, centrifugal enlargement of the lacrimal sac resulting from combined proximal and distal obstructions in lacrimal drainage system. Its presence in adults is an extremely rare event. The authors describe a case of giant lacrimal mucocele in an adult female presenting with only mild epiphora. The patient underwent aspiration of pus followed by external dacryocystorhinostomy (DCR). Patient's symptoms of epiphora resolved after surgery.

Анализ результатов хирургического лечения пациентов с облитерацией слезоотводящих путей вследствие терапии радиоактивным йодом

Relevance. Nasolacrimal duct obstruction occurs in 9% of patients after radioiodine therapy for thyroid cancer. The surgical interventions used in this case have not been studied enough; indications for certain operations have not been developed. Purpose. To evaluate clinical efficacy of surgical treatment in patients with nasolacrimal duct obstruction due to radioactive iodine therapy. Material and methods. The outcomes of 47 surgeries in patients with secondary acquired nasolacrimal duct obstruction due to radioiodine therapy were analyzed, among them 30 cases of dacryocystorinostomy and 17 cases of recanalization of the tear ducts. In 15 cases, dacryocystorinostomy was supplemented by the formation of an anastomosis in the area of the Hasner's valve. A comparative analysis of the effectiveness of surgical intervention depending on the localization of obstruction was carried out. Results. Dacryocystorinostomy was effective in 90% of cases, recanalization of the tear ducts – in 13% of cases. The analysis revealed that in cases of obstruction at the level of the lacrimal sac, the success of dacryocystorinostomy was 100% (5 observations), with obstruction at the level of the middle part of the nasolacrimal duct – 85.7% (12 observations), with obstruction at the level of the Hasner's valve – 100% (6 observations). Recanalization of the tear ducts was characterized by success in 100% of cases (1 observation) with obstruction of the middle part of the nasolacrimal duct and in 6.3% of cases (1 observation) with obstruction at the level of Hasner's valve. Conclusion. Dacryocystorinostomy is an effective intervention in patients with secondary acquired nasolacrimal duct obstruction due to radioiodine therapy. Recanalization of the tear ducts is characterized by low efficiency. The analysis of the effectiveness of these interventions, considering the localization of obstruction of the tear ducts, showed that the effectiveness of surgical treatment may vary depending on the level of obstruction. In cases of anatomically low obstruction of the tear ducts, dacryocystorinostomy was supplemented by the formation of an anastomosis in the area of the Hasner's valve. Recanalization of the tear ducts was characterized by greater efficiency in cases where the level of obstruction of the tear ducts was higher than the Hasner's valve than directly at Hasner's valve. The choice of treatment tactics for patients with secondary acquired nasolacrimal duct obstruction due to radioiodine therapy should be differentiated depending on the localization of the tear duct obstruction. Key words: tear ducts, radioiodine, dacryocystorhinostomy, nasolacrimal duct intubation

Lacrimal Sac Rhinosporidiosis: Clinical Profile and Gram Stain as a Method of Preoperative Diagnosis.

To describe the clinical profile of lacrimal sac rhinosporidiosis and to introduce a method for preoperative microbial identification of rhinosporidiosis using Gram stain. This is a prospective study, carried out from January 2016 to January 2022. This series included 18 patients with clinical suspicion of lacrimal sac rhinosporidiosis. All patients underwent a comprehensive eye check-up. Mucopurulent discharge collected by a sterile swab after applying pressure over the sac area and Gram staining was done. All patients underwent dacryocystectomy. The sac contents were sent for histopathology, and rhinosporidiosis was confirmed. A total of 18 patients over a period of 6 years with suspicion of lacrimal sac rhinosporidiosis were included. There were 11 (61.1%) male patients. Ten patients (55.5 %) had a history of either regular or occasional bathing in stagnant water. Nontender doughy swelling over the lacrimal sac region was the most common presentation. Gram staining of the mucopurulent discharge revealed thick-walled sporangia with endospores suggestive of rhinosporidiosis in all these cases. All patients underwent dacryocystectomy. Hematoxylin and eosin sections confirmed the diagnosis. Two patients had recurrence within 6 months after surgery. Regurgitation of pus mixed with whitish granular particles or blood is highly suspicious of rhinosporidiosis. In clinically suspected cases, microbial diagnosis using Gram stain is an economical, office procedure, which helps the surgeon to plan for the surgery and for better counseling.

Endoscopıc Anatomy of the Lacrımal Sac: A Cadaverıc Study.

To describe the anatomy of the lacrimal sac in relation to the lateral nasal wall by cadaver dissection, and to measure the distances of surgically important landmarks from relevant structures for safer and more efficient surgery. A total of 12 endoscopic dacryocystorhinostomy (DCR) were performed on both sides (right and left) of 6 fresh-frozen cadavers. The distances of the lacrimal sac to the posterior edge of the uncinate process, the frontal process of the maxilla, the maxillary ostium, the nasal vestibule, the middle turbinate attachment and the inferior turbinate were measured. In addition, the width and length of the lacrimal sac were measured. The mean width and length of the lacrimal sac were 5.6 mm and 11.1 mm, respectively. The lacrimal sac was located at 15.2 mm from the posterior edge of the uncinate process, at 35.5 mm from the nasal vestibule, at 13.5 mm from the maxillary ostium, at 12.2 mm from the frontal process of the maxilla, at 8.7 mm from the middle turbinate attachment, and at 7.3 mm from the inferior turbinate. This study provides additional measurements regarding the lacrimal sac and its relationships with nearby landmarks for use in endoscopic dacryocystorhinostomy. The distances of the lacrimal sac to the nasal vestibule, the uncinate process and the frontal process of the maxilla are not as reliable as the middle turbinate attachment for predicting the anatomic localization of the lacrimal sac during DCR.

Intradermal suture post-surgical scar in external dacryocystorhinostomy: technique and patient satisfaction survey

Purpose: Dacryocystorhinostomy surgery may result in significant postoperative scarring. Although other surgical techniques have been developed that achieve a better aesthetic result, the ab externo technique remains the gold standard for this procedure. We developed a telephone survey to evaluate the visual impact of postoperative skin scars associated with ab externo dacryocystorhinostomy. Methods: 470 patients underwent uncomplicated external dacryocystorhinostomy surgery by two consultant surgeons from January 2014 to December 2021. Skin incisions were closed using intradermic continuous suture with prolene 6.0. The exclusion criteria were cases of dacryo-phlegmon and lacrimal sac fistulae with skin maceration. The visual effect of the postoperative scar was evaluated, and the degree of patient satisfaction was measured by a questionnaire with four subjective perceptions of the scar (very good, good, bad, very bad) given by a physician in the first postoperative month. The survey responses were used as the basis for a literature review. Results: The survey received 470 responses (100%) Very good perception of the scar was achieved in 75,8% of patients. There were no other post-operative complications noted from medical records review. Conclusions: Given the small percentage of patients who complained of marked scarring, it should not be the main reason for deciding on the procedure for dacryocystorhinostomy, especially in elderly patients. Therefore, the surgical technique should be considered as a surgically acceptable choice if cosmetic results were selection criteria in the case of total stenosis of the nasolacrimal duct.

Morphometry of the Bony Orbit and Periorbital Structures: Personal Perspectives From Decades of Related Research.

The author introduces his personal perspectives on the bony orbit, nerves, arteries, and ligaments relating to orbital re- construction surgery. A supraorbital fissure was 40.0 ± 2.5 mm from the supraorbital notch. Posterior ethmoidal foramen was 31.7 ± 3.0 mm from the anterior lacrimal crest. The infraorbital fissure, where the infraorbital groove started, was 26.4 ± 2.6 mm from the infraorbital foramen. The supraorbital fissure was 34.3 ± 2.7 mm from the frontozygomatic suture. The medial palpebral ligament consisted of 2 layers. The superficial layer of the palpebral ligament (SMPL) was from the anterior lacrimal crest to the upper and lower tarsal plates. The deep layer of the palpebral ligament (DMPL) lay from the anterior lacrimal crest to the posterior lacrimal crest, covering the lacrimal sac. Horner muscle was at the posterior lacrimal crest just lateral to the attachment of the DLPL and ran laterally to the tarsal plate deep to the SLPL. Three components of the lateral canthal area are: (1) lateral palpebral raphe, (2) superficial lateral palpebral ligament (SLPL), and (3) deep lateral palpebral ligament (DLPL). The lateral ends of superior and inferior orbicularis oculi muscles interlaced at the lateral commissure and formed the lateral palpebral raphe. The superficial lateral palpebral ligament extended from the lateral ends of the tarsal plate to the periosteum of the lateral orbital rim. The lateral palpebral ligament extended from the lateral ends of the tarsal plate deep to the origin of SLPL to the Whitnall tu- bercle on the zygomatic bone. The palpebral branch of the in- fraorbital artery emerged from the infraorbital foramen and ran superior and lateral to the orbital septum. After passing through the orbital septum, distributed to the orbital fat.

Nasolacrimal Duct Coronary Stent Recanalization (NCR): First Cadaver Experience and Its Potential as an Alternative to DCR.

To investigate the feasibility of implanting a drug-eluting cobalt-chromium alloy coronary stent in the nasolacrimal ducts (NLDs) of human cadavers. The pilot study was carried out in 5 NLDs of 4 adult human cadavers. Sirolimus-eluting coronary stents of 2 mm in width and lengths of 8 and 12 mm, which were mounted on balloon catheters, were used. Following dilatation of the NLDs, the balloon catheters were introduced into the NLDs under direct endoscopy guidance. The stents were delivered following dilatation of the balloon to 12 ATMs and secured in a locked (spring out) position. The balloon is then deflated and securely extubated. The dacryoendoscopy confirmed the stent position. The lacrimal system was then dissected to assess several key parameters like the uniformity of the NLD expansion, anatomical interactions of the NLD mucosa with the stent rings and struts, integrity of the soft and bony NLD, stent movement on mechanical push and pull, and ease of manual removal. The cobalt-chromium alloy coronary stents could be delivered with ease and secured in the cadaveric NLDs. Its position was confirmed by a dacryoendoscopy and later by the direct NLD dissection. The NLD was uniformly dilated 360° with a wide and uniform lumen. NLD mucosa was noted to be uniformly distributed in spaces between the stent rings without influencing the expanded lumen. Following the lacrimal sac's dissection, the NLD stent showed significant resistance to downward movement but could be easily retrieved with forceps. The 12-mm stents could reach the near total length of the NLD with good luminal expansion. The integrity of the bony and soft-tissue NLD was maintained. The learning curve is shallow if the surgeon is adept with the techniques of balloon dacryoplasty. Drug-eluting cobalt-chromium alloy coronary stents can be precisely deployed and secured within the human NLDs. The study is the first of its kind to demonstrate the technique of NLD coronary stent recanalization in human cadavers. It is a step forward in the journey to evaluate their use in patients with primary acquired NLD obstructions and other NLD disorders.

Toll-Like Receptor Signaling in the Pathogenesis of Chronic Dacryocystitis: Implication of c-FOS Transcription Factor and its Downstream Effector Chemokine Genes CCL2, CCL4, CXCL3, CXCR4 with a Shift of the M1/M2 Macrophage Phenotype.

TLRs are fundamental elements in the orchestration of the innate immune system. These receptors seem to be responsible for the inflammation and fibrosis in chronic dacryocystitis. The aim of the present study was to investigate the role of the toll-Like receptors (TLR2 and TLR4) signaling pathway and its downstream effector chemokine genes in the pathogenesis of chronic dacryocystitis. This study was conducted on 20 patients diagnosed with chronic dacryocystitis and underwent external dacryocystorhinostomy. Estimation of gene expression of TLR2, TLR4, CCL2, CCL4, CXCL3, CXCR4, and c-FOS genes in the lacrimal sac tissues was performed together with the assessment of the inflammatory markers TNFα, IL-1β, IFN-γ, and IL-22. Histopathological examination of the lacrimal sac walls using hematoxylin and eosin (H&E) stain, in addition to immunohistochemical staining of the CD68 and CD163 macrophage markers, was also performed. Our results showed that TLR2, TLR4, and c-FOS gene expressions were significantly increased in the chronic dacryocystitis group with a subsequent increase in their downstream effector chemokine genes CCL2, CCL4, and CXCL3. This up-regulation of genes was accompanied by macrophage shift of polarization toward the M1 pro-inflammatory phenotype (increased CD68 and decreased CD163 expression), leading to increased levels of the pro-inflammatory cytokines (TNF- α, IL-1β and IFN-γ) and decreased anti-inflammatory marker IL-22 with chronic dacryocystitis. It is essential to fine-tune TLR activation through emerging therapeutic approaches. Targeting TLR signaling at the level of receptors or downstream adaptor molecules represents a new challenge for treating chronic dacryocystitis.

Lacrimal Drainage Infections with Sphingomonas paucimobilis: Clinical Presentations, Complications and Outcomes

Purpose To report the clinical presentations, complications, and outcomes of Sphingomonas paucimobilis-specific lacrimal drainage infections. Methods A retrospective chart review of all patients diagnosed with Sphingomonas paucimobilis lacrimal infections and managed at a tertiary care Dacryology Service from November 2015 to May 2022 over a 6.5-year period were recruited and analyzed. Data collected include demographic details, clinical presentation, microbiological diagnosis, antibiotic susceptibility profiles, management, complications, and outcomes. The microbiological techniques employed were aerobic and anaerobic cultures, phenotypic identification with VITEK 2R system, polymerase chain reaction, antibiotic sensitivity profile and minimal inhibitory concentration. Results Twelve Sphingomonas-specific lacrimal drainage infections of 11 patients were identified. Of these five were canaliculitis and seven were acute dacryocystitis. All the seven acute dacryocystitis presented in an advanced stage; five were with lacrimal abscess and two with orbital cellulitis. The antibiotic susceptibility profile of canaliculitis and acute dacryocystitis were comparable and the organism was sensitive to several classes of antibiotics. The outcomes of punctal dilatation and nonincisional curettage were effective for canaliculitis. Patients with acute dacryocystitis had advanced clinical stage at presentation but responded well to intensive systemic management and had excellent anatomical and functional outcomes with dacryocystorhinostomy. Conclusion Sphingomonas-specific lacrimal sac infections can have aggressive clinical presentations and need early and intensive therapy. The outcomes are excellent with multimodal management.